Chronic pain is now considered as the fifth vital sign.[1] The International Association for the Study of Pain defines pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”[2]

Pain is always a subjective experience. It is a symptom responsible for detecting any injury or insult to any part of the body, and helps in preventing any further damage. This is true in acute pain but not in chronic pain.

May it be a physical or psychological pain! If the patient is not able to communicate about his/her condition that does not mean that he/she is not having pain. Whenever we experience pain, there is an unpleasant sensation, which is an emotional aspect. According to this definition, pain may be present even if there is no tissue damage and thus, the definition avoids binding pain to the actual stimuli. In short, pain has sensory, emotional, and cognitive aspects, and it impacts patients' function, affective status, and quality of life.[2]

There are many advances happening in treating the physical pain, but the psychological pain still remains underdiagnosed, less researched, and undertreated.

There are some patients who are reluctant or are not able to reproduce their pain score, and if they are forced on, they may give wrong information. This is because they are not able to rate their emotional and psychological condition.[3] This shows that emotional component plays a vital role in patients' overall pain expression.

Pain management as a super specialty is developing rapidly in India. The Indian Society for Study of Pain is running many projects for improving pain awareness and knowledge. There is a rapid rise in the number of pain physicians in every part of India. It is the right time to ask ourselves, if we are on the right path?

Dame Cicely Saunders defined the concept of total pain as “the suffering that encompasses all of a person's physical, psychological, social, spiritual, and practical struggles.”[4]

Are we treating “total pain” or are we just concentrating on managing physical aspect of pain?

Chronic pain presents a huge challenge to the patients' quality of life. It not only affects their physical health but also affects their psychological well-being. Their productivity is negatively affected, and they face financial problems. In most cases, by medical interventions, we cannot resolve the pain completely. In such cases, we need special approaches including psychological treatments. This approach does not focus on the resolution of patient's pain. It concentrates on the patient's improvement in physical functioning and emotional and social well-being. It also involves occupational guidance, which helps in reducing their financial problems.

When we deal with the psychological aspect of pain, we must understand the following:

How the patient copes with the pain and how it influences his/her experience of pain. There are various coping styles (problem-solving, active coping, information seeking, support seeking, reappraisal/reframing, distraction, praying, hoping, catastrophizing, escape, or avoidance)[3]

Depression may be a predictor of pain severity and is true vice versa [3]

Early intervention is the key to prevent these complex disorders associated with pain [3]

Malingering and deception are the possibilities found in patients with pain, and identification of factors increasing this likelihood is an important aspect of patient management [3]

Caretakers (family, health-care providers, employers, third-party payers) around the patients may blame them for excessive pain complaints (avoiding family responsibilities or for financial gains from the employer). There are a few who may say that all the pain is in the patients' “head”—that is, psychogenic pain. This may lead to impaired relationship between patients and their caretakers.

There are various ways to deal with psychological issues in patients with pain.

Cognitive behavior therapy (CBT): This is one of the most common and widely accepted modality in managing psychological aspects in patients with chronic pain. In this therapy, the focus is on how peoples' beliefs and attitudes alter their physical, affective, and behavioral factors.[5] This is a short-term goal-oriented psychotherapy. Its goal is to change the way people think and respond to their pain. It is a combination of psychotherapy and behavioral therapy. It is now known that the persons' reaction to any event is by their learned experiences rather than their automatic reflex. Patients with chronic pain have fixed beliefs about their inability to control some motor skills, and that they do not have any control over their pain (negative maladaptation appraisals). This leads to demoralization, reduced movements and activities, and exaggerated reaction to pain.[5] They feel helpless. For successful treatment, whole patients' support system (caretakers) has to be educated and involved. Their support helps the patient to remain compliant with the treatment. CBT teaches the patient to gain a sense of control of pain, and its effect on the body and life. Various techniques include self-monitoring, distraction by the use of imagery, and problem-solving.[5] The therapy helps in gaining control over one's behavioral, cognitive, affective, and sensory responses to pain. It changes the patient's perspective about how they should deal with pain and belief about pain. CBT helps in developing new way of thinking, new beliefs, and behavior in response to their pain. It also helps in improving distorted thinking (e.g., catastrophizing—negative thoughts about one's pain condition and exaggerated response to a minor situation like a catastrophe). Coping training, i.e. effort to keep working in spite of pain, helps in handling the pain and distress in a far better way. This helps in altering pain intensity perception and one's ability to manage the pain.[5]

Biofeedback therapy [6]: Biofeedback is a mind–body technique in which an individual learns how to modify their physiology for the purpose of improving physical, mental, emotional, and spiritual health. It is a self-regulatory technique; the patients learn to control some of the involuntary body processes. To convert physiological signals into meaningful visual and auditory responses, special equipment is used under the guidance of a trained biofeedback practitioner. The patient looks on the computer monitor, gets the feedback that helps in developing control over their physiology. By looking into the mirror, the patient can learn to change their positions, expressions, and so on. Surface Electromyography (EMG), skin temperature, electroencephalography, heart rate monitor, and electrodermal activity are used to monitor the physiological response. Under stress, the heart rate, muscle tension, and sweating increase. The patient visualizes this on the monitor. The therapist teaches the patient to control these stress responses. They teach relaxation exercises such as deep breathing, progressive muscle relaxation (alternate tightening and relaxing), guided imagery (to focus on the specific image that makes the patient relaxed), and mindfulness (focusing on the thoughts and letting go of negative emotions). This requires training sessions and regular practice at home. Over time, the patient learns this without the use of monitors.[6]

The evidence for biofeedback in various conditions such as chronic pain, anxiety, headache (adults), and Temporomandibular (TM) joint disorder is Level 4 (efficacious). The evidence in arthritis is Level 3 (probably efficacious). In fibromyalgia, it is Level 2 (possible efficacious).[6]

Mindfulness-based stress reduction (MBSR): MBSR program is a technique developed by Dr. Jon Kabat-Zinn in 1979.[7] The central component of this therapy is mindfulness meditation. It was originally designed for stress reduction.[8],[9] But now it is used for many chronic illnesses including chronic pain. The stress induces many aforementioned changes. The program constitutes of 2.5 h/week, 8-week course with a 1-day retreat.[10]

The program includes sitting meditation, walking meditation, hatha yoga, and body scan—a sustained mindfulness practice in which attention is sequentially focused on different parts of the body.[10] Another important component is the transition of mindfulness into everyday life.

In one study, 77 patients took part in MBSR program. Over 200 medical centers across the world offer MBSR as an alternative treatment option to patients. Approximately 51% showed improvement in the global well-being, pain, sleep, fatigue, and early morning fatigue.[11]

Although the evidence for MBSR is insufficient, the result suggests that MBSR may be a useful tool in managing chronic pain–associated stress.

Acceptance and commitment therapy: This is the form of therapy where patients with pain are assisted and engaged in flexible and persistent pattern of value-directed behavior while they are in pain. There are two ways in which it helps: reducing the effort to control pain and improving valued living by increasing the frequency of activities. The American Psychological Association considers this as a strong intervention to manage chronic illnesses including pain.[12]

Conclusion

In India, with hundreds of pain clinics coming up every year, it is important for us to include psychological management as an important part of our multidisciplinary pain clinic. We must concentrate on the concept of treating “total pain.” Apart from medical, interventional, and physical therapy treatments, we must also focus on treating patient's psychological pain. There are many ways to manage them including CBT, biofeedback, MBSR, and acceptance and commitment therapy. It is the right time that we understand the concept of “total pain,” and give the patient best possible treatment to manage their pain.